PRURITUS ANI

of agricultural dusts during operations such as threshing, applying fertilizers, and preparing animal feeds. California's agricultural workers have the highest rate of occupational disease of any industry in that State, and the same is probably true of the United States as a whole. A report of the United States Department of Health, Education and Welfare, in 1963, shows that in the years from 1959 to 1961, the number of persons injured at work per 100 currently employed were: rural farm, 16·7; rural non-farm, 13·2; urban, 12·8. There appears to be little comparable information in Australia, but Professor A. Brownlea, Head of the School of Australian Environmental Studies, University of Griffith, has informed me that the preliminary results of an analysis of admissions to certain hospitals in Queensland show that, on this basis, morbidity rates of a surprising number of important diseases are higher in rural than urban areas. The whole area of health legislation and services for farmers is as yet very underdeveloped. Strangely, Poland is reported to be one of the few countries where the rural worker may have received the same attention as his urban counterpart. Most advanced countries have given relatively little attention to rural health, or disease. Recently in Australia, for instance, there has been much concern and industrial trouble about the possibility that abattoir workers might be infected with Brucella abortus, but very little attention has been given to the much greater risk of farmers and veterinarians being so infected. The 4th Report of the Joint ILO-WHO Committee of Occupational Health (1962) emphasized the need for better cooperation between physicians and veterinary surgeons in rural areas, and Schwabestates that joint scientific meetings of medical and veterinary societies have become increasingly common in both the United States and Britain, but need continuing encouragement. Clearly, much more attention needs to be given to the health of the rural community, but perhaps the most basic problem is to halt the steady relative economic decline of the rural, as compared with the urban, community. University of Queensland, J. FRANCIS, Department of Veterinary Head of Department. Pathology and Public Health, Veterinary School, St Lucia, Brisbane, Qld 4067.


TORSION OF THE TESTIS
SIR: Although the two-glass urine test described by D. Jorgensen' is of some diagnostic value in adults with lower genitourinary tract inflammation, it is of little or no value in the management of the painful scrotum in patients under the age of 21 years. Such patients require an immediate open surgical exploration of the testis and appendages, both in order to make an accurate diagnosis and to possibly prevent delayed death of the testis. 2 The Gardens Medical Centre, RONALD B. BROWN. 50 Nelson Road, Box Hill, Vic. 3128.
, Jorgensen, D., MED. J. AUST., 1972, 2: 342. 2 Allan, W. R., and Brown, R. B., Brit. med. J., 1966Brit. med. J., , 1: 1396 SPIRONOLACTONE AND ACUTE MOUNTAIN SICKNESS SIR: Dr T. T. Currie (Journal,March 19) has continued to make a number of disconcertingly inaccurate conclusions in reply to my letter (Journal, December 11, 1976). I suggested that the initial hypothesis, that acute mountain sickness (AMS) was caused by an inappropriate secretion of antidiuretic hormone (ADH) and aldosterone,' was untenable because of contradictory evidence. His criticism of this evidence was partly based on the false assumption that I proposed that AMS was caused by decreased aldosterone production. I raised no such alternative hypothesis.
First, J. R. Sutton-has also indicated that the use of spironolactone was based on an hypothesis which appears vulnerable. He concluded that "on balance it seems that aldosterone secretion decreases at altitude and that the hypothesis has been refuted". His argument is based on six reports-of decreased aldosterone secretion in response to altitude, and one study' looking at the severity of AMS, which showed a definite decrease in aldosterone. Further report has been made recently of decreased aldosterone levels in climbers, the lowest levels being found in sufferers from AMS.4 After the publication of this evidence, Dr Currie cited a 1972publication5 which summarized the then conflicting evidence about aldosterone levels at altitude. It was unscientific to propose a hypothesis in the face of this conflicting evidence.
Second, the value of plasma cortisol levels is irrelevant to this hypothesis. However, to reiterate my previous point in answer to Dr Currie, despite the tripling in cortisol levels on arrival at altitude, Singh et alii" showed that a sudden drop in plasma cortisol levels was associated with the heralding fall in urinary output, and the occurrence of high altitude pulmonary oedema. This drop did not occur in unaffected subjects. Thus it would be erroneous to associate AMS with inappropriate adrenocortical overactivity.
Third, Dr Currie sees that fact that Singh et alii" were unable to estimate the degree to which lesser adrenocortical activity contributed to the illness as important to his argument. Independent of any record of urine output, they irrefutably state that less adrenocortical activity existed in unacclimatized rather than acclimatized subjects.
Dr Currie suggests that spironolactone is effective only' because of its action against the agonist aldosterone. Evidence exists to suggest that this drug has effects independent of mineralocorticoid antagonism, including its antihypertensive" and diuretic actions. 0 Although hypertension is not a phenomenon of AMS, peripheral vasoconstriction is thought to be an important factor. For example, vasoconstriction in response to cold is a recognized precipitating event.' 0 Thus, peripheral vasodilation, the mode of action of many antihypertensives, is beneficial as demonstrated by the therapeutic effects of morphine in AMS. Also spironolactone decreases cerebral oedema l l and cerebrospinal fluid (CSF) secretion!" independent of its aldosterone antagonism. Both these factors are thought to play a role in AMS. Similarly acetazolamide's usefulness in prophylaxis may, in part, be explained by its action of decreasing CSF production. ,2 Finally, Dr Currie's statement that a central movement of blood volume occurs with hypocapnia is contrary to physiological evidence."? Hypercapnia and hypoxia are associated with an increased cerebral blood flow and cerebral vasodilation. This is an additional basic error in the continued elaboration of a disproved hypothesis. PRURITUS ANI SIR: The article by Tom Turner' on Pruritus Ani was comprehensive and sound, but possibly a further point could be made which concerns the role of the surgeon in the management of this condition. Although local perianal pathological changes such as skin tag, haemorrhoid, fistula, or fissure may be significant, more proximal gut disease, not so readily visible, is also important.
A sigmoidoscopy will often disclose an area of granularity of rectal mucosa with excess mucus, which, by leaking on to perianal DEPARTMENTAL COMPUTERIZED ACCOUNTING form unrelated to the needs of the unit. Accounting is usually limited to the purchasing officer keeping records of purchases and items currently outstanding. The system is labour intensive and not used efficiently, especially by others, given the individual traits common to manual tasks. Thus, the maximum amount of information useful to the department is not readily available for informed forward planning.

TYPES OF RECURRENCES IN MENTAL BREAKDOWNS
We have had a computerized accounting system operating in our department for three years and consider the following advantages to be worth while: (i) readability and accuracy; (ii) advance expenditure planning; (iii) detailed monitoring of expenditure by categories and by individuals; (iv) check on central accounting and variation in orders and invoices; (v) ability to highlight outstanding orders, and (vi) low operating cost and release of clerical time for other tasks. In a climate of financial restraint and high inflation, it surely makes sense for even the most academic of departments to consider optimizing return on their restricted budgets. The question as to whether air pollution in Port Kembla, Whyalla, Port Augusta, or Port Pirie can affect the sex ratio of births or masculinity of still births is in one sense the tip of the iceberg (J ournal, September 24). Forgetting"P values", "statistically random reciprocation" and so on, the message that comes through loud and clear is that trace mineral deficiencies and excesses can bring about silent and to date unrecognized changes extending well beyond the subject matter raised in Dr Lyster's letter. It is a classical effect that the physiological and biochemical changes which are induced by trace-mineral deficiencies lead to structural changes that bear little relation to the original deficiency. Before pollution from the local industries is blamed, one would have to consider several other factors which might, by trace mineral interaction, exert an effect.
How much do the individuals in the survey drink and smoke? Does drinking and smoking produce excessive zinc and magnesium loss, possibly accelerating any cadmium overload? Do they live in a selenium deficient area? What is their selenium intake? Have they been eating locally grown vegetables and what was the cadmium content of the superphosphate used? There are innumerable related questions.
Experimental evidence suggests that trace mineral deficiencies and excesses are responsible for a wide range of congenital abnormalities, including permanent postnatal behavioural problems, as well as producing still births and miscarriages. While industrial pollution is certainly a factor, self-pollution is just as important, though we like to forget it. Air pollution is just one of many factors which can impair the vitality and mobility of the Y-chromosome-bearing sperm. Where there is smoke, there is fire.
Molecular skin as Dr Turner describes can initiate or perpetuate the pruritus ani cycle. A biopsy of the granular area, which may be quite localized, occasionally shows histological changes suggestive of ulcerative colitis, but more often shows non-specific changes. When such areas of granularity and excess mucus are found, a short course of prednisolone suppositories, combined with longer term therapy of sulphasalazine administered orally, will dry up the mucus, and contribute significantly to the improvement of the perianal irritation.
201 Macquarie Street, J. McL. HUNN. Hobart, Tas. 7000. I Turner, T., MED. J. AUST., 1977,2: 335. SIR: In my opinion, the type of either nervous or mental breakdown that any individual will have under stress is determined developmentally, and is probably due to a genetic factor. By nervous or mental breakdown I mean a definite neurotic or mental illness, not just a state of anxiety, or worry, or misery. An actual illness of either type occurs at the point that the symptoms reach a point of irreversibility" At this point, both types of illnesses need active psychiatric treatment.
Once a person has had a particular neurosis or psychosis and recovers, and then has a recurrent breakdown, I consider that he or she always has a similar type of breakdown and does not switch to a different type of breakdown. Anxiety neurosis illness repeats itself as anxiety neurosis, manic-depressive psychosis repeats itself as manic-depressive illness, schizophrenic illness repeats itself as schizophrenic illness, and hysterical illness repeats itself as hysterical illness.
Diagnoses such as schizo-affective illnesses are, I think, suspect, and more detailed investigation will determine into which slot they will drop. Grey areas of the psychoneuroses are complicated by the influence of character growth and need much further investigation. Breakdowns associated with physical brain disorders are not relevant to my letter as they can mimic any psychiatric illness.
Childhood breakdowns are often presented as disorders of conduct, but many do occur as in adults. Some children are born with developmental brain disorders, or disorders that result from brain trauma or brain shock at birth. Some children are born with such sensitive brains that they completely and permanently break down at some trivial stress, as did one child of 18 months I remember, who broke down at the barking of a dog. Others who partially break down under stress develop autistic illness which mayor may not be curable.
My basic contention is that once a type of breakdown is established in a person, it repeats itself in further breakdowns of that person. This has been my experience in a very long association with the practice of psychiatry.
SIR: The use of computers for accounting procedures in the business world is well established, yet very few academic or servicedepartments in hospitals and universities make use of an automated accounting system. Most rely on a centralized administration which provides monthly balances and lists of items passed for payment, often in a ARTERIAL DISEASE SIR: Dr G. R. Osborn's classical work on coronary disease shows the importance of the effect of sensitivity to chemicals upon blood vessels, especially cows' milk intolerance in the very young. It is